Form TSA 1164 TSA 1164 Mental Health Certification

Mental Health Certification

Mental Health Certification

Instructions: Please read the following statements carefully. To certify that a statement is true, place your initials on the line next to the statement. For those statements for which you are unable to certify, you must provide an explanation. Inability to certify for one or more statements only indicates the need for further information, and does not necessarily adversely affect eligibility for further consideration. Please type or print legibly in the space provided. You may use additional sheets of paper to explain any response that requires additional space. If additional pages are attached, please be certain each page contains your full name and identifies each explanation provided by the number of the question addressed. If you need assistance, please contact the FAMS Medical Programs Branch at (609) 813-3050. Please send the completed form to (609) 872-1937 (fax) or mail to FAM Medical, 200 West Parkway Drive, Suite 300, Egg Harbor Township, 08234.

Name:

     

Date:

Address:

     

     

     

Street City and State Zip Code

Phone:

     

Email:

     

____1. I have never had a job where the responsibilities were restricted or withdrawn for medical or psychological reasons.

     

____2. I have never previously held (nor do I currently hold) a security clearance where my access has been suspended or withdrawn

due to a medical or suitability reason.

     

____3. My capacity to hold a license, permit, or practice in a profession has never been restricted or withdrawn (i.e., driver's license,

permit to carry a concealed weapon, or certification to practice in a regulated occupation or profession).

     

____4. I have never been required to undergo a mental health examination in order to return to work.

     

____5. I have never been removed from work for medical or psychological reasons.

     

____6. I have never been prescribed medication to reduce anxiety, depression or to help with sleep.

     

____7. I have never been referred for mental health care for which I did not obtain treatment.

     

____8. I have never participated in a substance abuse (alcohol or drug) rehabilitation program.

     

____9. I have never participated in a behavioral or conduct control program (i.e., anger management, gambling, or pornography

addiction).

     

____10. I have never been found to be an unfit parent or guardian.

     

____11. I have never been the subject of a restraining order or protective order.

     

____12. I have never consulted with a mental health professional (psychiatrist, psychologist, counselor, etc.) and have never consulted

with another health care provider about a mental health related condition.

I,	     	, certify that all statements made by me on this form are true, complete and
Print Full Name
correct to the best of my knowledge and belief, and are made in good faith.
Signature			Date

PRIVACY ACT STATEMENT: Authority: 49 U.S.C. § 114(n), 14 C.F.R. Part 67, E.O. 9397 (SSN). Principal Purpose(s): This information will be used to determine your suitability to serve as a Federal Air Marshal. Routine Use(s): This information may be shared in response to a request for discovery or for an appearance of a witness, information that is relevant to the subject matter involved in a pending judicial or administrative proceeding, or for routine uses identified in the Office of Personnel Management's system of records notice, OPM/GOVT-10 Employee Medical File System Records (if hired) or OPM/GOVT-5 Recruiting, Examining, and Placement Records (if not hired). Disclosure: Voluntary; failure to furnish the requested information may result in an inability to consider you for a position as a Federal Air Marshal. Failure to provide your SSN may result in a delay in determining your suitability to serve as a Federal Air Marshal.

PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: TSA is collecting this information about you to determine your suitability to serve as a Federal Air Marshal.  This is a voluntary collection of information; however, failure to furnish the requested information may result in an inability to consider you for a position as a Federal Air Marshal.  TSA estimates that the total average burden per response associated with this collection is approximately one hour (or 15 minutes if not submitting an explanation).  If you have any comments regarding this form, you can write to TSA, Office of Law Enforcement/Federal Air Marshal Service, 601 S. 12^th Street, Arlington, VA 22202. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number.  The control number assigned to this collection is OMB 1652-0043, which expires 03/31/2016.

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TSA Form 1164, December 2007 OMB control number 1652-0043; Expiration Date 3/31/2016